Organization
EVERGREEN PEDIATRICS, LLC
Active
Organization
EVERGREEN PEDIATRICS, LLC
Active
Other names
Evergreen Conifer Pediatrics
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KENNETH JOHN KUTALEK M.D. (OWNER)
(303) 674-6671
Entity
Organization
Contact information
Practice address
30960 STAGECOACH BLVD, SUITE W-120, EVERGREEN, CO 80439-7902
(303) 674-6671
(303) 674-0031
Mailing address
30960 STAGECOACH BLVD, SUITE W-120, EVERGREEN, CO 80439-7902
(303) 674-6671
(303) 674-0031
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
26133
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01261338
—
CO
05
—
04007977
—
CO
05
—
40308332
—
CO
Enumeration date
07/24/2008
Last updated
07/24/2008
Update your record
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